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Encounter data duplicate logic

January 2024

Developed by the Health Industry Collaboration Effort (HICE) Encounters Standardization Team, this template was created to capture the data elements currently in use by various industry organizations for duplicate check logic, including the California Department of Health Care Services, the Centers for Medicare and Medicaid Services (CMS), FinThrive, and participating health plans.

Author

Health Industry Collaboration Effort (HICE) Encounters Standardization Team

Why use it

The Encounter Data Duplicate Logic template supports Provider Organizations and Delegates that work with claims or encounters. If a health plan rejects an encounter for a duplicate claim, you can use this information to review the claim and then determine which data element that is or is not on the claim could be causing the duplicate rejection. This report is designed to be a quick tool and resource when performing encounter reconciliation.

Who it’s for

The Encounter Data Duplicate Logic template is intended for healthcare organizations, such as provider organizations and delegates, that work with claims or encounters.

Key take-aways

This report is a resource to facilitate review of requirements across the board to identify the potential cause of duplicate rejections. If a plan rejects an encounter for a duplicate claim, providers and delegates can use this information to review the claim and then determine which data element that is or is not on the claim could be causing the duplicate rejection. It includes the data elements currently in use by various industry organizations for duplicate check logic.

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IHA’s Resource Hub is made possible through a grant from Health Net, LLC’s Encounter Data Improvement Program.

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